Thin It to Win It: Competition in Eating Disorder Treatment

When you have an eating disorder (particularly anorexia), people react in one of two ways. Either they want to get you help– or they’re jealous. Obviously, the latter group has some issues of its own. Patients still, however, take in those reactions. It’s everything from, “Wow, I wish I had that much self-control,” to “My goodness you’re so tiny!” or worse, “Tell me how you do it.” The most damaging part of these comments? They don’t stop at the threshold to treatment.

Whether you attend group therapy, intensive outpatient, or especially inpatient/residential treatment, the competition and the comments still happen. We eating disorder patients like to believe (as do our loved ones) that negative body-talk ends when you show up for therapy. Unfortunately, this is usually not the case.

What I really want to focus on is how this takes place in residential treatment settings. From my own experiences and those of others, it seems that there’s a much higher incidence of this sort of competition and negativity on adolescent units than adults’. I think this has a lot to do with the fact that the vast majority of adolescent girls in eating disorder treatment are not there voluntarily. There were put there by parents and doctors and therapists who are, according to them, taking away the only thing that they have any say over, the only thing that belongs to them. So many of these girls stage underground mutinies, banding together in subversion of the system, helping each other dodge rules and restrictions and staff. And while this creates a great deal of comradery, it has the unfortunate effect of keeping everyone sick. Because on the other side of the wall are a bunch of very sad, frightened little girls, consumed by shame, self-hatred, and guilt. And at the same time that they are acting like a team they are also competing to be the thinnest, the sickest, the best at this disease.

I don’t think this gets talked about enough. We often hear about pro-anorexia web sites and models who got airbrushed on magazine covers; what we don’t often think of is the influence other patients have on us in treatment. The first few times I went to group therapy and intensive outpatient the only thing I got out of it was an array of new eating disorder tricks. I constantly compared my body to the others in the group (even the therapists!) and never stopped obsessing about whether or not they were judging me for not being thin enough or sick enough to “deserve” treatment. During my first experience in a residential treatment center (RTC), my two roommates and I developed a late night calisthenics routine that we did after lights out, trying to see who could go the longest before their meds kicked in. One of those roommates asked me to teach her how to throw up. (That, I refused to do, knowing it would only open the door to a whole new kind of hell she would eventually have to escape from. If she got there on her own, whatever. But I was not going to be responsible for helping someone go there.) Needless to say, recovery did not even get a foothold there. It was like this in all the adolescent units I visited. Every now and then one of us would get a grip and go, Come on, guys, I’m really trying to eat here, or Maybe you should listen to your therapist, and everyone would feel kind of guilty and it would quiet down…for a little while. Then people would start to get anxious again and it would go right back to the way it was: everyone outwardly cooperating, while secretly judging each other and themselves for not being good enough.

Things work a little differently in adult RTCs. And again, I believe the major factor is whether or not you’re there on a voluntary basis. There also seems to a connection between programs that are located in medical hospitals as opposed to those that are located in houses, etc.; in my experience there is more noncompliance and competition and negativity in hospital environments than in others. (Note: This is just my experience and may be a gross generalization.) Whatever the program’s location, from what I’ve seen the same sort of things that happen on adolescent units still happen on adults’, just much less. People in adult programs are mostly there because they’re sick and they know it and it was either go to treatment or die and they didn’t want to die so they went to treatment. Most of these people are still ambivalent about recovery. There are others who are totally ready for it, and still others who just felt forced to come and don’t care at all. This can create some interesting group dynamics that are much more complex than those of the adolescents’ milieu. Mostly I think the competition and judging is reduced to everyone’s’ heads and journals and individual therapists; we patients are still constantly over analyzing, judging, and worrying about being judged. We are still wanting to be the thinnest, we still compare bodies; we just don’t do it as openly anymore. We are more aware of the fact that some people really are trying to recover. A lot of that is because we are no longer teenagers, who are genetically programmed to be egocentric. Still, we are all worried we are not sick enough, not good enough, not enough period.

What lies beneath this competition is more than just insecurity. That feeling, that fear of not being sick enough, is not about vanity or rivalry; it’s about feeling so worthless that you don’t believe you deserve to be cared for. That’s what it comes down to. People with anorexia and bulimia don’t believe that they deserve help, deserve rest, deserve to ask for what they need. In other words, they don’t believe they get to be human. And when they compete with each other to be the thinnest, the sickest, what they’re really doing is trying to prove that they’re worthy to be in treatment; worthy of the time and energy of the staff; worthy to nourish their bodies, worthy to start to heal. There are some places that address the issue of competition among peers and that is to be commended. I wish more of that would happen. Because the more it is brought out into the open, the more we patients can focus our energy on fighting our eating disorders– instead of each other.

© Sarah Henderson 2010